forms

Opt Out

NOTE: BC Medical Plan (MSP) Provincial Healthcare is not acceptable as alternate coverage.

Already have coverage?

Coordinating multiple plans: If you are an eligible student and have comparable coverage you may wish to coordinate your plans. Benefits under the two plans can be coordinated to increase your coverage up to 100% of the actual expense(s) incurred. For example, following payment under this plan you can submit outstanding balances to the other plan for consideration. Find out more about coordination of benefits.

Opting Out of coverage:
Students are given 1 opportunity at the start of their academic year to opt-out of the health and/or dental plan(s). If you previously opted out, you do not need to opt out as your opt out will carry forward each year, if they remain an eligible student.

NO EXCEPTIONS will be made if the deadline is missed. It is the student's responsibility to pay the plan fees, should they miss the applicable opt-out deadline.

Approval of the Students opt-out will result in the plan fee being credited/or refunded according to the school's policy and will remain in force if the Student remains eligible.

Please read and agree to the Terms & Conditions prior to submitting your online opt-out.

If you are unsure if you are eligible, to confirm the applicable deadline or if you have any questions regarding the Student Health and Dental Plan, please contact the Student Benefit Office.
Please read and agree to the Terms & Conditions prior to submitting your online opt-out.

Have a safe and healthy year!

Thank you

Lansdowne Campus
101B Fisher Building
3100 Foul Bay Road
Victoria, BC V8P 5J2
Phone: 250-370-3696
Fax: 250-370-3636
Email: ccssplan@camosun.bc.ca

Interurban Campus
Campus Centre 111
4461 Interurban Road
Victoria, BC V9E 2C1
Phone: 250-370-3869
Fax: 250-370-3830
Email: interurbanplan@camosun.bc.ca

Student Information

Student ID Number

Email Address

Confirm Email Address

First Name

Last Name

Date of Birth

Date Month Field Date Day Field Date Year Field

Mailing Address

City

Province

Postal Code

Phone Number

Phone Area Number Phone Local Number Phone Digits

Campus

Program Name

Program Start Date

Date Month Field Date Day Field Date Year Field

Required Direct Deposit Information

Please enter your financial institution's Transit Number, Institution Number, and Account Number. (*mandatory fields)

** Please do not enter any dashes or spaces **

Transit #

Institution #

Account #

Opt In

If a student has successfully completed an opt-out but requires re-enrolment into the plan there are 2 opportunities to do so:

1) Upon Program Start Date Anniversary: For students starting in September the anniversary would be the following September prior to the applicable deadline. For students starting in January the anniversary would be the following January prior to the applicable deadline.

2) Lifestyle Change: There are certain circumstances known as lifestyle changes that allow a student to make changes to their enrolment status within 30 days of the change date. Lifestyle changes include; getting married, meeting the twelve-month co-habitation requirement for common law status, birth/adoption of a child, meeting provincial plan residency requirements and losing their alternate coverage.

Students who lose their comparable coverage may opt back into the Student Benefit Plan(s), if they are within 30 days of losing coverage. If a student has lost their comparable coverage, they must provide documentation of loss by submitting a letter from either the insurance carrier or employer stating the date coverage ends, the carrier name and policy number.

Student Health and Dental Plan coverage is provided to eligible students automatically, except in certain circumstances where a student’s enrolment status excludes them from automatic inclusion by the institution or due to a previous waiver on file. To enroll in the Student Health and/or Dental plan(s), complete the sections below and submit this form. The Student will then be contacted by the Benefit Plan Office, via an email notification, of any required supporting documents and fees. All supporting document(s) and fees must be received by the applicable deadline for the enrolment process to be completed.
Please read and agree to the Terms & Conditions prior to submitting your online Enrolment Form.

Have a safe and healthy year!

Thank you

Lansdowne Campus
101B Fisher Building
3100 Foul Bay Road
Victoria, BC V8P 5J2
Phone: 250-370-3696
Fax: 250-370-3636
Email: ccssplan@camosun.bc.ca

Interurban Campus
Campus Centre 111
4461 Interurban Road
Victoria, BC V9E 2C1
Phone: 250-370-3869
Fax: 250-370-3830
Email: interurbanplan@camosun.bc.ca

Student Information

Student ID Number

Email Address

Confirm Email Address

First Name

Last Name

Gender

MaleFemale

Date of Birth

Date Month Field Date Day Field Date Year Field

Phone Number

Phone Area Number Phone Local Number Phone Digits

Campus

Program Name

Program Start Date

Date Month Field Date Day Field Date Year Field

The myBenefits Card is an important piece of identification that will ease access to your benefits. All eligible students must complete the myBenefits Card Registration Form. This multi-purpose card provides your policy information for submission of claims at both the Pharmacy and the Dental Office.

To obtain your myBenefits Card you must first register for BC Fair Pharmacare.

Student Information

Student ID Number

Email Address

Confirm Email Address

First Name

Last Name

Gender

MaleFemale

Date of Birth

Date Month Field Date Day Field Date Year Field

Phone Number

Phone Area Number Phone Local Number Phone Digits

Campus

Program Name

Program Start Date

Date Month Field Date Day Field Date Year Field

British Columbian Students - Please list your BC Fair PharmaCare Number
Out of Province Students - Please list your home province
International Students - Please list your country of residence

BC Fair PharmaCare Registration No.

Please indicate how you would like to access your benefits card

Please send an electronic version of myBenefits Card to the email address provide above
I will pick up my Benefits Card on Campus

Enrolment in the Student Health and Dental plan not guaranteed by submitting this form. The Student must be eligible for the program. Should you have any questions regarding the enrolment process please contact CCSS Member Services prior to submitting this form.

I understand the information provided above is required in order to obtain the said pay direct drug card. I hereby authorize and consent to the use, release, and exchange of the above information between the institution, the student organization, the Student Service Co-ordinator, Gallivan & Associates, BCE Emergis Assure Health Division, and the insurance carrier(s) to be used solely in connection with the Student Benefits Plan. I confirm that all the information provided herein is accurate. I also understand that the Student Service Coordinator may need to notify the institution to find out whether or not I have paid for the plan.

I Agree to the Terms & Conditions

Family Add On

Coverage provided through the Student Health and Dental Plan can be extended to a spouse and/or dependent(s). To add eligible dependent(s) complete the sections below and submit this form. The Student will be contacted via email by the Benefit Plan Office of any required supporting documents and fees. All supporting document(s) and fees must be received by the applicable deadline in order for the family add on process to be completed. The Student must also be enrolled in the Student Health and Dental Plan.

IMPORTANT! The fees for Family Add-on are in addition to the student health and dental fee.

Spouse Eligibility

Spouse is defined as your spouse by marriage or under any other formal union recognized by law, or your common-law spouse.

Common-Law Spouse is a person who has been living with you in a conjugal relationship continuously for a period of not less than one year or who is the natural or adoptive parent of a child of who you are also the parent.

Spouse means the person who is a resident of Canada, and who is married to the student or a person of either sex who have been continuously cohabitating with the student for a period of at least one year and who is publicly represented as the student’s wife or husband.

Dependent Children Eligibility

Children are defined as your natural children, stepchildren, legally adopted children, and children for whom you/and or your spouse have been appointed as guardian(s) for all purposed pursuant to an Order of the Court. NOTE: if the child is your stepchild or your spouse’s adopted child or a child for whom your spouse has been appointed guardian, both your spouse and the children must reside with you full-time. In addition, the child must be:

Unmarried
Under 21 years of age and not employed full-time
Under 25 years of age, if they are attending a college or university full-time, or
Physically or mentally incapable of self-support and became incapable to that extent while entirely dependent on the student for maintenance and support and while eligible under 1) or 2) above

NOTE: Parents, Grandparents, Siblings are not eligible dependents.

2019 - 2020 Family Add-On Fees:
Health (one or more dependent) $140.00
Dental (one dependent) $185.00
Dental (two or more dependents) $260.00

Please read and agree to the Terms & Conditions prior to submitting your online Family Add-On form.

Have a safe and healthy year!

Thank you

Lansdowne Campus
101B Fisher Building
3100 Foul Bay Road
Victoria, BC V8P 5J2
Phone: 250-370-3696
Fax: 250-370-3636
Email: ccssplan@camosun.bc.ca

Interurban Campus
Campus Centre 111
4461 Interurban Road
Victoria, BC V9E 2C1
Phone: 250-370-3869
Fax: 250-370-3830
Email: interurbanplan@camosun.bc.ca